Despite ongoing attention to rising rates of hospital-acquired infections and efforts to stem this growth,1 limited focus has been given to whether physicians and other health care personnel contribute to workplace transmission of illness by choosing to work when ill.2- 4Presenteeism —the act of working while ill—has important implications for health care personnel, whose repeated interactions with patients make productivity declines from illness more dangerous and disease transmission more likely. While the pressure to work while ill is common across all health care workers, the demand among resident physicians may be particularly great due to pressure from peers and lack of an adequate system of coverage.5,6 Most residents report coming to work when sick at least once annually, with rates varying little according to sex, specialty, or hospital. These results suggest that presenteeism is ubiquitous and not confined to specific specialties or hospital cultures.5,6 Despite evidence that most residents work when ill, little is known about the reasons they choose to do so.

Methods

We conducted a paper-based, anonymous, in-person survey of 150 resident physicians present during the 2010 meeting of the American College of Physicians, Illinois chapter. The sample included residents from 20 internal medicine programs in Illinois. We asked residents whether they worked with flulike symptoms in the prior training year and, if so, their reasons for doing so. Ethical approval of the study was granted by the institutional review board at the University of Chicago Hospitals.

Results

Presenteeism among residents was common: 77 residents reported working with flulike symptoms at least once in the last year (51%), and 24 reported working sick at least 3 times (16%). Although not statistically significant at the P < .05 level, several important trends were found. Second-year residents were more likely to report working when sick than first-year residents (58% vs 51%) (P = .51). Male residents were less likely to work while sick than female residents (48% vs 56%) (P = .22). When residents were asked whether they believed that they ever directly transmitted an illness to a patient, 14 responded yes (9%), while 32 believed that there were instances in which other sick residents transmitted their illness to a patient (21%).

Among residents who chose to work when sick, the most frequently reported reasons were an obligation to colleagues and an obligation to patient care (57% and 56% of all residents, respectively) (Table). Few residents stated that they worked when sick because they were afraid other colleagues would think they were “weak” (12%); 8% of all residents reported working when ill because they felt pressured to repay colleagues who would otherwise have to cover their missed clinical responsibilities. Second-year residents were more likely than first-year residents to state that responsibility to patient care prohibited them from taking time off for sickness (60% vs 46%) (P = .21), while female residents were more likely than male residents to place patient care as a reason for presenteeism (65% vs 49%) (P = .14). Compared with male residents, female residents were more likely to report working when ill because they were afraid of being perceived as weak (18% vs 7%) (P = .16).

Comment

Although drawn from a nonrepresentative sample of residents, our findings are consistent with national estimates of the prevalence of presenteeism among residents.5,6 Our results provide the first-ever information to our knowledge on the reasons that residents in the United States choose to work when sick. Residents appear driven mainly by a sense of obligation to patients and colleagues, exemplified by higher rates of presenteeism among more senior residents, who traditionally shoulder more responsibility for unifying care for a team's patients and therefore may feel more pressured to provide care when sick.

The practice of presenteeism by resident physicians raises important questions about the development of professionalism in young physicians. Deciding among conflicting values and resolving ethical and moral decisions is basic to this process. On the one hand, sick residents may be motivated to work when sick because of their duty to care for their patients, dedication to work, loyalty to colleagues, and possible fear of institutional reprisal. On the other hand, residents may be conflicted by the ethical injunction against harming patients; their own scientific knowledge and awareness of the risks of exposing patients, colleagues, and staff to potential illness; and their professional obligation to perform at their best when caring for patients. High rates of presenteeism highlight that the current balance of these values is in favor of coming to work sick.

Resident presenteeism should be better identified and addressed by medical educators and residency leaders. In addition to adequate systems of coverage and occupational health guidelines regarding working when ill, faculty should ensure that residents are taught that refraining from work while ill is the best and most professional way to ensure responsible and safe care for patients.

Author Contributions: Dr Jena had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Jena, Meltzer, and Arora. Acquisition of data: Press and Arora. Analysis and interpretation of data: Jena, Meltzer, and Arora. Drafting of the manuscript: Jena and Arora. Critical revision of the manuscript for important intellectual content: Jena, Meltzer, Press, and Arora. Statistical analysis: Jena. Administrative, technical, and material support: Arora. Study supervision: Meltzer and Arora.

Financial Disclosure: None reported.

Funding/Support: This research was supported in part by grants from the National Institutes of Health and the Agency for Healthcare Research and Quality (Dr Meltzer) and from the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine Foundation (Dr Arora).

Role of the Sponsors: Funding agencies were not involved in study design; collection, management, analysis, or interpretation of data; or manuscript preparation.